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Member or Pharmacy Central Online Forms.

If you need a copy of a particular form, ConnectiCare's Online Form Resource can save you time. To obtain a copy of a specific form, please click on the form by name below. A description and directions for use will appear.

All forms are in PDF format. The freely available Adobe Acrobat Reader is required to view and print PDF files.

All forms are the exclusive property of ConnectiCare, or used by ConnectiCare with permission, and protected by copyright. All forms are to be used solely for business with ConnectiCare.

Enrollment/Change Form

Connecticut Family Health Statement Form

Student Verification Form

Disabled Dependent Form

Prescription Drug Reimbursement Claim Form

Prescription Drug Mail Pharmacy Order Form

Out-Of-Plan Reimbursement Form

Asthma Control Plan

Birth Expectations Survey

Childbirth Preparation Class Reimbursement Form

Infertility Treatment and Procedures Disclosure Form

ConnectiCare Solo Electronic Funds Transfer Form

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Enrollment/Change Form:

Connecticut Domiciled Group - Fully Insured Employers

Connecticut Domiciled Group - Fully Insured Employers (for use with FlexPOS plans)

Massachusetts Domiciled Group - Fully Insured Employers (if member is enrolling in ConnectiCare Network USA, please use ConnectiCare Network USA . See form below.)

New York Domiciled Group

ConnectiCare Customized - Self Funded Employers

ConnectiCare Network USA (PPO plans)

Please Note:
If you are unsure as to which form to use, please consult with your Employer to obtain the correct Enrollment/Change form.

If you are seeking to:

Add a dependent.
Remove a dependent.
Terminate enrollment.
Change plans.
Elect COBRA coverage.
Change your name or marital status.
Change your OB/GYN.
Change your address.*
Change your primary care physician.*
Order a replacement card.*

*In most cases, this information may also be changed online through the Managing Your Account screens.

NOTE: In order to print this form, you must set your print properties to:

Fit to Page if you are using Adobe Acrobat 4.0 or Shrink oversized pages to paper size if you are using Adobe Acrobat 5.0

Print the form.
Fill in the necessary information and sign the form.
Submit the form to your employer. (Note: this form will not be accepted from the subscriber directly.)
If you have any questions, call ConnectiCare’s Member Services Department at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

Please Note:
For small employer groups only (1-50 full-time employees) – a CT Family Health Statement Form must accompany the Enrollment/Change Form if you are a new hire, a new group, or enrolling at your annual open enrollment period. This form is not required for members enrolling in Massachusetts plans.

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Connecticut Family Health Statement Form

If you are an employee of a Connecticut small employer group (Employer with 1-50 full-time employees) and you are seeking to enroll yourself or a dependent.

Print the form.
Fill in the appropriate information.
All questions to which you have answered "yes" on the Family Health Statement Form must be explained in the space provided on the form. If additional space is needed, attach a separate piece of paper.
Forward the Health Statement Form along with your completed Enrollment Form to your Benefits Office.
If you have any questions regarding the Family Health Statement Form, call ConnectiCare’s Group and Membership Administration Dept. at 1-800-333-1733, Monday through Friday 8:00 a.m. – 5:00 p.m., Eastern Time.

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Student Verification Form

If you are a Parent or Guardian of a dependent student who is either reaching the age of 19, or is currently enrolling in college and is within the dependent age limit. *

*Please refer to your Benefits Office for age guidelines.

Please note: If you prefer to verify your dependent's student status online, please click here .

Print the form.
Complete, sign and date the form
Mail the completed form to ConnectiCare
If you have any questions, call ConnectiCare’s Member Services Department at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

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Disabled Dependent Form	If you are a Parent or Guardian of a disabled dependent, and you are requesting that ConnectiCare health care coverage be continued for your dependent who has reached the maximum dependent age limit.	Print the form. Fill in the appropriate information. Forward the form to the accredited institution for completion and mailing to ConnectiCare. If you have any questions, call ConnectiCare’s Member Services Department at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

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Prescription Drug Reimbursement Claim Form

If you are seeking to receive reimbursement for prescriptions that were purchased without the use of your ConnectiCare ID Card.

Print the form.
Fill in the appropriate information.
Attach all receipts.
Mail the information to: ConnectiCare, Claims Dept., P.O. Box 546, Farmington, CT 06034.
If you have any questions, call ConnectiCare’s Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

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Prescription Drug Mail Pharmacy Order Form

If you are seeking to order a 90-day supply of maintenance prescription drugs through the mail.

Helpful Mail Order Hints
Print the form.
Fill in the appropriate information.
Attach the prescription(s) from your provider.
Enclose your payment.
Mail the information to Express Scripts, Attn: Mail Pharmacy, 3684 Marshall Lane, Bensalem, PA 19020-5914. .
If you have any questions, call Express Scripts' Customer Service Call Center, available 24 hours-a-day, 365 days-a-year at 1-800-369-0675

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Out-Of-Plan Reimbursement Form

If you are seeking to:

Obtain reimbursement for a medical service that you paid for out of your own pocket.
Request payment to be made to an out-of-plan or non-participating provider from whom you received a medical service.
Request coordination of benefits with your primary insurance company.

Print the form.
Follow the instructions on the form.
For Medical and Surgical Claims, mail this information to:
If you have any questions, call ConnectiCare’s Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

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Asthma Control Plan

If you are a ConnectiCare member and you have asthma. (This tool will help your physician or asthma specialist to design a plan to control your asthma.)

Print the form.
Bring the form to your next appointment with your primary care physician or asthma specialist, for discussion and plan development.
Keep the completed asthma plan easily available for quick reference.
If you would like additional information about asthma or would like to enroll in a Free Asthma Education class where you will receive a peak flow meter, a video, and educational materials, please call 1-800-390-3522.
If you have any questions, call ConnectiCare’s Health Management Programs at 1-800-390-3522, Monday through Friday 8:00 a.m. – 4:30 p.m., Eastern Time.

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Birth Expectations Survey

Click here to take this survey online.

If you are pregnant.

By completing this form we can get to know you and assist you in understanding important signs and symptoms, and to help you through your pregnancy. ConnectiCare is committed to assisting you during your pregnancy.

Print the form.
Answer all questions as completely as possible.
Mail this information to: ConnectiCare, Birth Expectations Survey, 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050.
If you have any questions, call ConnectiCare’s Health Management Programs at 1-800-390-3522, Monday through Friday 8:00 a.m. – 4:30 p.m., Eastern Time.

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Childbirth Preparation Class Reimbursement Form

If you are seeking to receive reimbursement for a childbirth preparation class.

Print the form.
Fill in the appropriate information.
Attach your payment receipt.
Mail this information to: ConnectiCare, Claims Dept., 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050.
If you have any questions, call ConnectiCare’s Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

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Infertility Treatment and Procedures Disclosure Form
Note: This form is located on the State of Connecticut website. When you choose this form, you are leaving ConnectiCare's website.

When you are seeking health insurance coverage for infertility treatment or procedures and have previously received infertility treatment or procedures for which you received coverage under a different health insurance policy.

Print the form.
Complete the form including signature and seal by a Notary Public.
Send the original form to ConnectiCare Inc., Attention: Clinical Review at 175 Scott Swamp Road, P.O. Box 4050, Farmington, CT 06034-4050.
If you have any questions, call ConnectiCare's Clinical Review department at 1-800-562-6833, Monday through Friday 8:00 a.m. - 5:00 p.m., Eastern Time.

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ConnectiCare Solo Electronic Funds Transfer Form

For ConnectiCare SOLO (individual) members who wish to make their payments electronically.

Print the form.
Complete the entire form, sign and date.
Mail the form along with a voided check or savings deposit ticket to: ConnectiCare, Inc and Affiliates, Attn: Billing/EFT, 175 Scott Swamp Road, Farmington, CT 06034-4050
If you have any questions, you can call ConnectiCare's Billing Dept. at 1-800-333-1733, Option #4, Monday through Friday 8:00 a.m. - 4:30 p.m., Eastern Time.

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